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LETTER TO EDITOR
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 43-44

Herpes zoster radiculopathy: A lesson in physical examination


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission22-Apr-2022
Date of Acceptance11-Nov-2022
Date of Web Publication23-Jan-2023

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/juoa.juoa_5_22

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How to cite this article:
Dharmshaktu GS, Agarwal N, Dharmshaktu IS. Herpes zoster radiculopathy: A lesson in physical examination. J Uttaranchal Orthop Assoc 2022;1:43-4

How to cite this URL:
Dharmshaktu GS, Agarwal N, Dharmshaktu IS. Herpes zoster radiculopathy: A lesson in physical examination. J Uttaranchal Orthop Assoc [serial online] 2022 [cited 2023 Feb 5];1:43-4. Available from: http://www.juoa.org/text.asp?2022/1/1/43/368389



Dear Editor,

Viral infection on rare instances may mimic sciatica-like pain.[1] Acute radiculopathy is a nagging problem that is commonly observed in routine clinics and disc-related disorders are major contributors. The evaluation warrants the exclusion of red flags in history and examination and reaches a provisional diagnosis and pain source. Imaging is used to confirm the diagnosis or exclude differentials. The appropriate diagnosis thus results in optimal treatment and recovery. In busy clinical settings, many a time, the common problems are hurriedly assessed to miss important clues to the diagnosis which then leads to inappropriate investigations or misdiagnosis. A thorough clinical assessment is crucial for not missing peculiar signs that may alter the course of management.

A 52-year-old male patient presented to us with chief complaints of acute radiculopathy to his right thigh and upper leg along with pain over the buttocks and lower back for the past 5 days. He had no history of trauma and was given symptomatic treatment at a local health-care center for transient relief. He had his radiographs done revealing no significant abnormality and was labeled as an acute disc prolapse case with rest and pain medication prescribed. He was also referred to a physiotherapy clinic for appropriate fomentation and other advice. During the inspection after undressing the lower back area by the physiotherapist, a clump of multiple small skin lesion were noted at the right upper gluteal area and the same was discussed with us [Figure 1]. The skin consultation confirmed it to be a healing clump of a vesiculobullous rash of localized herpes zoster infection. He was then prescribed acyclovir among other medications for gradual relief over the next week.
Figure 1: The clinical image showing the lower back area with a group of healing vesiculobullous eruptions of cutaneous herpes zoster infection over the right side with complaints of intense pain and radiculitis features

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Herpes zoster infection results from the varicella-zoster virus (VZV) that characteristically involves segmental dermatome distribution and presents with intense pain and allodynia.[2] Pain precedes typical rash formation and usually thoracic region is involved, but on rare instances, lumbar and thigh region involvement is also reported.[3] The clinical feature resembling discogenic pain should be thus assessed carefully to exclude uncommon causes such as viral infections. Sometimes, the rash may not be present over the lower back but in the foot or lateral ankle in the distribution of nerve and may pose a diagnostic challenge as reported in one case highlighting the importance of excluding VZV infection in all back pain cases.[4] Hip and calf areas also need to be inspected and may have a rash with no lower back lesion.[5] A good clinical inspection and examination results in a valid diagnosis in most cases of low back pain, and imaging should supplement not replace the clinical assessment. This small case snippet highlights the importance of having a quick examination protocol that can be used even in busy clinic and should be instrumental for appropriate diagnosis. The case also underlines the importance of cross-discipline evaluation of cases separately so that we do not miss woods for the trees.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hackenberg RK, von den Driesch A, König DP. Lower back pain with sciatic disorder following L5 dermatome caused by herpes Zoster infection. Orthop Rev (Pavia) 2015;7:6046.  Back to cited text no. 1
    
2.
Wareham DW, Breuer J. Herpes zoster. BMJ 2007;334:1211-5.  Back to cited text no. 2
    
3.
Mallepally AR, Mahajan R, Rustagi T, Marathe NA, Chhabra HS. Varicella-Zoster radiculitis mimicking sciatica: A diagnostic dilemma. Asian J Neurosurg 2020;15:666-9.  Back to cited text no. 3
  [Full text]  
4.
Koda M, Mannoji C, Oikawa M, Murakami M, Okamoto Y, Kon T, et al. Herpes zoster sciatica mimicking lumbar canal stenosis: A case report. BMC Res Notes 2015;8:320.  Back to cited text no. 4
    
5.
Wei FL, Li T, Song Y, Bai LY, Yuan Y, Zhou C, et al. Sciatic Herpes Zoster suspected of lumbar disc herniation: An infrequent case report and literature review. Front Surg 2021;8:663740.  Back to cited text no. 5
    


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